Kathryn Beattie died in June 2004, less than 24 hours after suffering what was later revealed to be a fatal brain haemorrhage caused by undiagnosed leukaemia.
The 13-year-old was taken to the Victoria Infirmary in Glasgow by ambulance following a bout of flu-like ill health at her home in the city which culminated in an episode where her speech had become slurred.
Sheriff Linda Ruxton, who presided over a Fatal Accident Inquiry (FAI) into Kathryn's death, said that there had been confusion among the medical team over who should instruct treatment when she arrived in hospital.
Staff were unaware that an on-call doctor was not a blood specialist, which led to the "misapprehension" that expert advice had been obtained and delayed the production of blood tests that could have provided a diagnosis of leukaemia.
However, Sheriff Ruxton said that despite the failings in her treatment, nothing could have been done to save Kathryn once bleeding had begun in her brain and the chance of her responding was "vanishingly small".
Sheriff Ruxton said that FAI proceedings had been undermined by the length of time it had taken for the case to be heard, as crucial details were lost to the mists of time. She said: "Delay of this magnitude inevitably affects the quality of the evidence available to the inquiry. Stated simply, memories fade and direct recollection may be lost."
The Sheriff said that the delay could have placed future patient safety "at risk" because relevant issues were left unresolved, adding: "It is intolerable that the relatives of the deceased person have to wait for so long for the inquiry to be held."
And she was concerned to discover that medical records were either "missing" or "silent or incomplete" for critical stages in Kathryn's care.
The Sheriff added: "The events relating to those three areas of evidence were fundamentally disputed by the family and the lack or absence of adequate records served to fuel the family's suspicions. Accurate and full notes of these important events would therefore have been of considerable assistance to the inquiry."
The Scottish Government has recently announced an overhaul of the FAI system. But ministers were criticised when it emerged that the planned changes would not speed up the process.
The FAI into Kathryn's death heard harrowing accounts of her death, with witnesses giving conflicting versions of events.
She was transferred to the Southern General Hospital where an operation was carried out to stop the bleeding in her brain. Although it was a success, the damage was she had already suffered was too severe and she died the next day.
Her mother Jean Crawford wept as she told the court that her daughter was left to die alone after her life support machine was switched off with no family by her side. Kathryn's father, Dr Gerald Beattie, was so distressed by the turn of events, he "burst through the curtains" and began breathing into the tube providing his daughter with oxygen.
However, doctors who gave evidence said they had followed correct procedures.
A spokesman for NHS Greater and Clyde said that it had changed its clinical services during the 10 years since Kathryn's death, and that Haematology and Biomedical Science on call arrangements are now entirely different.
A spokesman for the Crown Office said: "This was a lengthy and complex investigation which we carried out three years after Kathryn Beattie's death as it had not been reported to us at the time by either the hospital or her family. As the Sheriff has noted, the Crown's investigation was more difficult as a result.
"There were a number of unique aspects to this inquiry which resulted in it taking 19 months to hear all the evidence."
He added: "Since this death, the specialist Scottish Fatalities Investigation Unit (SFIU) has been set up within Crown Office to improve our process, we have reviewed our advice to NHS staff on the reporting of deaths and a new process of electronic reporting will be introduced shortly for the NHS."